a reflection on the successful outcome of effective ... · a reflection on the successful outcome...
TRANSCRIPT
A reflection on the successful
outcome of effective analgesia ina patient with a venous leg ulcerMaeve Coyle
Across cultures and across timeone of the most basic human
experiences is pain, which maybe acute or chronic (Madjar & Walton,1999). Addressing the control of pain,which is often the main concern in
patients with leg ulcers (Morrison etai, 1999) may lead to improvement inquality of life.
Pain in Venous Ulcers
There are two types of pain associated with
venous leg ulcers, neuropathic and nociceptive.
Neuropathic pain arises from damaged nerve
tissues (Mangwendeza, 2000). Nociceptive
pain, which is associated with trauma or injury
(Hall, 2003) results from actual or potential
tissue damage. Pain receptors may be excited
by mechanical, thermal or chemical stimuli and
they are especially common in the superficial
portions of the skin. Pricking or fast pain is
generally elicited by mechanical and thermal
type receptors whereas slow, aching pain can be
elicited by all three stimuli. Chemical substances
such as histamine, serotonin, prostaglandins and
cytokines are especially important in stimulating
the slow suffering type of pain that occurs from
epithelial and connective tissue injury (Martini &Bartholomew, 2000).
Tissue ischaemia is thought to cause pain because
of accumulation of large amounts of lactic acid in
the tissues. However, formation of bradykinin or
proteolytic enzymes from damaged cells may also
stimulate nerve endings (Guy ton, 1991).
Issues Related to Holistic Nursing Care
Provision of nursing care of patients with wounds
must begin with a comprehensive understanding
of the concept of pain. As well as physical
pain, those with chronic wounds also suffer
psychological, social and spiritual pain, and
their care must encompass all three dimensions
(Greenstreet, 2001). If true holistic care is to
be given physical aspects of pain cannot be
treated separately. However, observation and
measurement of physical pain are important
(Hawthorn and Redmond, 1998). Indeed
Moffatt(l999) identifies pain in chronic wounds
as a major issue in quality of life assessment.
Quality of life Issues
In this article I will focus on a patient in my
care and through reflection suggest that perhaps
there has not been enough consideration of
pain assessment and its documentation, with anassociated lack of evaluation of how effective
prescribed analgesia actually is. Research by
Charles (1995) identified pain as the worst aspect
of leg ulceration, a chronic condition which can
have a significant impact on the patients quality
of life (Cave, 1999).
Prevalence and Aetiology
A prevalence survey (O'Brien and Burke,
2002) in the Mid-Western Health Board region
of Ireland revealed a prevalence rate for leg
ulceration of 12/10,000. The prevalence increases
eightfold in the population over 70 years. The
average age of patients was found to be 72 years
and women were twice as likely to be affected as
men(O'Brien & Burke, 2002)
A recent study by Douglas (200 I) has shown
that 55% of patients with leg ulceration in the
United Kingdom are over 85 years of age. Itis also estimated that in the next two decades
the number of people aged over ninety is set to
double. This client group are often isolated due to
other medical conditions. Research into quality
of life in leg ulcer patients has found high levels
of social isolation, depression, anxiety (Keeling
et aI, 1996) and pain frequently compounds this
problem. Indeed a study by Moffatt (2001,a)
associated factors such as pain and depression
with delayed healing of leg ulcers. Low healing
rates together with high recurrence rates cause
untold suffering to the patient (Diamond, 1999).
Recurrence following healing is less common in
patients who comply with treatment programmes
(Tonge, 1995).
Maeve CoyleRGN,SCMStaff NurseOutpatients Department,Letterkenny General Hospital,Co. Donegal, Eire
LUF Journal Issue 17 - Autumn 2003 27
Reviewing the literature (Loveman & Gale, 2000;Greenstreet, 2001; Hawkins, 2001; Hollinworth,
2001) there were suggestions that wound pain
generally is poorly managed, indeed in leg ulcers
it may often be ignored (Mangwenwdeza, 2000).
Case StudyIneffective pain management was reflected
in practice with Mary, a seventy-two year old
married lady who presented to the hospital legulcer clinic for assessment. She had been treated
for the previous six months with four-layer
compression bandaging. The ulcer was on the
gaiter area of her left leg. A hydrogel to enable
autolytic debridement (Hollinworth, 2001) of
the wound bed was being used, together with a
secondary adhesive foam dressing. Granulation
tissue was beginning to fill the wound bed and
small islets of epithelium were visible. However
there were signs of tissue trauma around the edgeof the ulcer, which measured 3cms x 4.5cms.
Mary said she now dreaded the weekly dressing
changes as pain caused by removal of theadhesive foam was unbearable. Modern dressing
products such as adhesive foams, hydrocolloids
and films often cause pain and tissue trauma at
dressing changes due to their adhesive properties
(lones and Milton, 2000 a; Hollinworth, 2000).
Alginates may adhere to the wound when the
level of exudate decreases (lones and Milton,
2000b) causing further suffering and trauma.
Mofatt (200Ib) found that ritualistic procedures
involving dressing techniques often isolates the
wound from the patient. She found that among
nurses the evidence based care agenda supporting
wound care was still dominated by the biomedical
model. Also professionals felt ill-equipped to
face emotional and psychosocial issues raised by
patients. Mary had been prescribed paracetamol
I gramme four times daily, for the ulcer pain
which she described as a constant gnawing. She
reasoned that daily dressing changes without four
layer bandaging would help, she felt there wouldbe less adherence of the foam after 24 hours. She
also complained that she found the four layer
bandages hot, malodorous and bulky, she was
unwilling to tolerate them any longer. Hayward
(2002) found that there are many reasons for non
compliance with compression bandaging such as
pain, discomfort, immobility, social isolation due
to malodour or simply because the patient wants
to shower every day. Mary felt socially isolated
due to the malodour from the bandages, which
28 LUF Journal Issue 17 - Autumn 2003
was evident on the second day following dressing
changes. Due to the bulk of the bandages shecould not wear her normal shoes, instead she had
to resort to slippers, which were also moist andmalodorous due to excessive exudate.
Effects of pain on mobility, sleep andinfection
Walshe (1995) found that pain limits mobility
and interrupts sleep. Due to constant pain, Marywas too debilitated and tired to mobilise. Also
the constant ache in her leg prevented her from
having a good nights sleep. Poor management of
wound pain often leads to increased frequency
of infection, delayed healing and suppressed
inflammatory response (Flanagan, 1997) issues
which all complicate leg ulcer management.
Infection had been excluded in Mary's case as a
swab had been taken the previous week. Mary felt
that her district nurse, who was constantly rushingdue to her excessive caseload, had underestimated
the significance of her pain. Hollinworth (1999)
found that those inflicting wound pain often
dismiss its significance.
Perhaps there has not been enough consideration
given to pain assessment and its documentation,with an associated lack of evaluation of how
effective prescribed analgesia actually is.
Clearly more communication with the patient
when planning treatment is necessary, a finding
supported by Scherwitz et al (1997) who found
that more than anything the patient wants to
be acknowledged, seen and heard. Due to staff
shortages in the workplace nurses may not have
time to sit and talk to the patients or ask them
how they feel about their ulcer. Often talking
to the patients and comforting them contributes
to pain relief (Pediani, 1998). Bernason et al
(1998) concluded that although pain control
was a priority in nursing care, pain managementwas ineffective and inconsistent. Often the
nurses perception of how much pain the patient
is experiencing differs greatly from what the
patients are actually suffering (Carr, 1997).
Language and ethnic differences can impedeeffective communication; however, nurses are
becoming increasingly aware of these differences
(O'Keefe, 2001). It was explained to Mary that
compression of the oedematous leg, plus elevation
to aid venous return and reduce swelling (Moffatt
& Harper, 1997) would in turn reduce pain. The
explanations were made using diagrams showing
lymphatic drainage plus venous return to the
heart. Use of the diagram aided her understanding
of the importance of leg elevation. Bradley (200 I)
acknowledges that sharing knowledge at the
patients level of understanding may help them
to grasp the importance of interventions such as
compression bandaging.
The vascular consultant prescribed Co-proxamol,
two tablets, three times daily plus Zimovane
7.5mg nocte to induce sleep, as inappropriately
managed pain is often associated with sleep
disturbance (Hofman, 1997). A home help was
arranged to help with the housework and cooking
so that Mary could rest and relax more with her
legs elevated. The occupational therapist was
asked to assess her home for grant aid for the
addition of a shower and toilet on the ground
floor of the house, a traditional two-storey. The
leg ulcer nurse specialist, in consultation with
the vascular surgeon suggested the use of short
stretch cohesive bandages, the weave of these
bandages allowing for minimal stretch and recoil,
resulting in a low resting pressure (Hayward,
2002). Mary agreed to try them for four weeks.Instead of the adhesive foam a soft silicone
dressing (Mepitel) was applied over the ulcer, a
dressing which has been shown to reduce wound
pain in children with partial -thickness scalds(Gotschall, 1998). When Mary returned to the
clinic four weeks later she felt that her quality
of life had improved. Her physical pain haddecreased as well as the size of the ulcer, and the
swelling in her leg had also reduced. She was
happy to be able to wear her normal shoes.
Pain Assessment Tools
A phenomenological study by Thomas (2000) on
the lives of individuals suffering non malignant
chronic pain found that most participants
described the pain as unremitting torment, which
affected the way they viewed their bodies.
Participants did not perceive nurses as supportive
of their pain experience even though they were
actively involved and ethically bound to deliver
quality care. Pain in venous ulcers may be
excruciating (Hollinworth, 2001) or 'bursting',
'heavy' or 'dull' (Moffatt, 1998). Many patients
may experience nocturnal pain which affects their
sleep (Liew et. aI., 2000). Pain management is an
important aspect of leg ulcer care (Mangwendeza,
2000). However physical pain is subjective
in nature, therefore difficult to measure. Pain
assessment tools can provide a quantitative
assessment of the degree of the patients suffering
Effective analgesia in a patient witha venous leg ulcer (continued)
(Harlos and Dudgeon, 1998). The Chronic
Limb Venous Insufficiency Questionnaire
(CLVIQ) (Franks and Moffatt, 1998) may beused as a means of addressing and evaluating
pain management. However the McGill Pain
Questionnaire (MPQ) is the one favoured in my
workplace as it is thought to be more useful than
the CLVIQ for assessing pain in wounds generally
(Gaglese and Melzack, 1997). Incorporation of a
valid pain assessment tool into wound care plans
has been suggested to the wound care committee.
Wound pain isdistressing and
debilitating but itcan be minimised by
appropriate assessmentand management
techniques
Conclusion
The wide-ranging consequences of pain in
wounds, a complex phenomenon, is perhaps
often ignored by caregivers (Flurrie, 2001).
Wound pain is distressing and debilitating but it
can be minimised by appropriate assessment and
management techniques (Hollinworth, 200 I).
Management of pain in leg ulcers by nurses is
often inadequate and research has shown that
continuing education raises awareness and
enhances standards (Mangwendeza, 2000). Flurrie
(200 I) suggests that quality of life measurementtools are vital. Franks and Moffatt (1999) suggestthat these studies should illustrate a holistic view
of the patient rather than focussing on the woundalone. There is a need to channel resources into
the setting-up of dedicated pain clinics for leg
LUF Journollssue 17 - Autumn 2003 29
ulcer patients, where health education aimed at
primary prevention (Ewles and Simnett, 1999)
and promoting healthier lifestyle choices would
make better use of scare resources. Briggs
and Torra i Bou (1999) suggest that adequate
analgesia may benefit wound healing rates.
Early audits in the North Western Health Board
area show high healing rates, with cost effectiveevidence based care and a reduction in recurrence
rates for patients who have access to established
leg ulcer clinics (Diamond, 1999). This case study
has implications for future wound care planning
in the authors workplace so that nurses can
continue to promote clinically effective outcomes,
utilising evidence based, cost effective, trueholistic care. MC
Acknowledgements
The author acknowledges the clinical guidance
provided by Mrs. P. Diamond, North Western
Health Board, Wound Management Facilitator.Also the invaluable assistance of Ms. Lilian
Bradley, Tissue Viability Nurse, Ulster
Community and Hospitals, HSS Trust/Lecturer,
School of Nurs.ing and Midwifery, Queens
University, Belfast, where the author is currently
studying for a Diploma in Health Studies (Wound
Management and Tissue Viability pathway).
ReferencesBernason, S., Merboth, M., Pozehl, B., and lietjen, M.J. (1998)
Utilising an outcomes approach to improve pain management by
nurses: a pilot study. Clinical Nurse Specialist. 12(1), pp. 28-36.
Bradley, L. (2001) Venous haemodynamics and the effects of
compression stocking. British Journal of Community Nursing. 6(4),
pp. 165-175.
Briggs, M., and Torra i Bou, J.E. (1999). Pain at wound dressing
changes: a guide to management. EWMA Position Document
pp. 12-17, European Wound Management Association, London:
Medical Education Partnership Ltd.
Carr, E. (1997) Assessing pain: a vital part of nursing care. Nursing
limes. 93(38), pp. 45-48.
Cave, J. (1999) Recent developments in community leg ulcer
management. British Journal of Community Nursing, 4(6), pp.296-302.
Charles, H. (1995) The impact of leg ulcers on patients quality of
life. Professional Nurse, 10(9), pp. 571-574.
Diamond, P.(1999) Establishing a leg ulcer service. Wound Care
Today, March, p. 2.
Douglas, V. (2001) Living with a chronic leg ulcer: an insight into
patients experiences and feelings. Journal of Wound Care, 10(9) pp355-359.
Ewles, L. and Simnett, I. (1999) Promoting Health; A Practical Guide
(4th Edition) Edinburgh: Balliere lindall in association with the
Royal College of Nursing (RCN).
Flanagan, M. (1997) Wound Management. Edinburgh: Churchill
Livingstone.
Flurrie, K.L. (2001) Care Study: the effect of pain on a patient with
leg ulcers. British Journal of Nursing, 10(13), pp. 868-878.
Franks. P.J.and Moffatt, c.J. (1999) Quality of life issues in chronic
wound management. British Journal of Community Nursing, 4(6),
pp. 283-289.
Gaglese, L., and Melzack, R. (1997) Chronic pain in elderly people.
Pain, 70, pp. 3-14.
GOlschall, C.S. (1998) Prospective randomised study of the efficacy
of Mepitel on children with partial-thickness scalds. Journal of
Burn Care Rehabilitation, 19(4), pp. 279-283.
30 LUF Joumallssuc 17 - Autumn 2003
Greenstreet, W. (2001) The concept of total pain: a focused patient
care study. British Journal of Nursing, 10(19), pp. 1248-1255.
Guy ton, A.C. (1991) Textbook of Medical Physiology (8th edition)
Philadelphia:W.B. Saunders Co. pp. 520-521.
Hall, M. (2003) Target Pain. Irish Nurse, 5(7) March 2003, pp. 23-25.
Harlos, M.S., and Dudgeon, D. (1998) In: McDonald, N. (ed.)
Palliative Medicine. pp. 192-203. Oxford: Oxford University Press.
Hawkins, J. (2001) A new cohesive short stretch bandage and its
application. British Journal of Nursing, 10(4), pp. 249-253.
Hawthorn, J. and Redmond, K. (1998) Pain, Causes and
Management. London: Blackwell Science.
Hayward, L. (2002) Patient-centred leg ulcer care. Nursing Times
Plus, 98 January 10th.
Hofman, J. (1997) 'Pain in venous leg ulcers'. Journal of Wound
Care, 6(5), pp. 222-224.
Hollinworth, H. (1999) Conflict or Diplomacy? Nursing Times,
95(34) pp. 63-68.
Hollinworth, H. (2000) Pain and Wound Care. Woundcare Society
Education Leaflet, 7(2).
Hollinworth, H. (2001) Pain relief. Nursing Times Plus, 97(28).
Practice guide.
Jones, V., and Milton, T. (2000 a) When and how to use hydrocolloid
dressings. Nursing Times, 96(4), pp. 5-7.
Jones, V. and Milton, T. (2000 b) When and how to use alginates.
Nursing limes Plus, 96(29) pp. 2-3.
Keeling,D.I.,et. al. (1996)Social support:some pragmatic
implications for health care professionals. Journal of Advanced
Nursing,23(1 ),pp.76-81.
Liew, I.H., Law, K.A., and Sinha, S.N. (2000) Do leg ulcer clinics
improve patients quality of life? Journal of Wound Care, 9(9), pp.423-326.
Loveman, E•• and Gale, A. (2000) Factors influencing nurses
inferences about patient pain. British Journal of Nursing, 9(6), pp.334-337.
Madjar, I., and Walton, J.A. (Eds.) (1999) Nursing and the
experience of illness: phenomenology in practice. pp. 123-124.
London and New York: Routledge.
Mangwendeza, A. (2000) Identifying pain associated with leg
ulceration. Journal of Community Nursing, 14(7), pp. 21-30.
Martini, EH., and Bartholomew, E.F. (2000) Essentials of Anatomy
and Physiology, (2nd edition) p. 272 New Jersey: Prentice-Hall, Ine.
Moffatt, c.J., and Harper, P. (1997) Access to Clinical Education: Leg
Ulcers. Edinburgh: Churchill Livingstone.
Moffatt, C. (1998) Issues in the assessment of leg ulceration.
Journal of Wound Care, 7(9), pp. 469-473.
Moffatt, C. (1999) Pain at wound dressing changes, Position
Document, European Wound Management Association (EWMA), p.
1 London: Medical Education Partnership Ltd.
Moffatt, C. (2001 a) The psychosocial effects of leg ulceration. The
Leg Ulcer forum Journal, 14, Spring 2001, p. 20.
Moffatt, C. (2001 b) Non-healing leg ulceration. Nursing limes Plus,
97(35), p.
Morrison, M., Moffatt, c., Bridel-Nixon, J. and Bale, S. (1999) A
Colour Guide to the Nursing Management of Chronic Wounds.
London: Mosby.
O'Brien, E and Burke, P. (2002) Prevalence and Aetiology of Leg
Ulcers in Ireland. Guidelines for the Management of Leg Ulcers in
Ireland. Grace, P. (Editor) pp. 7-' O. Dublin: Smith and Nephew Ltd.
O'Keefe, N. (2001) Pain and children. The World of Irish Nursing, 10,
pp. 34-36.
Pediani, R. (1998) A reflection on nursing time. Journal of Advanced
Nursing, 28, pp. 693-694.
Scherwitz, L.W" Rowntrees, R" and Delevitt, P. (1997) Wound
caring is more than wound care: the provider as a partner. Ostomy!
Wound Management, 43(9), pp. 42-56.
Thomas, S.P. (2000) A phenomenological study of chronic pain.
Western Journal of Nursing Research, October; 22, pp. 683-699.
Tonge, H. (1995) A review of the factors affecting compliance in
patients with leg ulcers. Journal of Wound Care, 4(2), pp. 98-99.
Walshe, C. (1995) Living with a venous leg ulcer: a descriptive
study of patients experiences. Journal of Advanced Nursing, 22(6),
pp. 1062-1110.17